Lab 3 Upper Extremity Part 2. Range of Motion

Case Study A 55 year old man who works in a ware house as a clerical worker has complained of pain and discomfort above his elbow on the lateral side. He has discomfort in the area plus in the posterior compartment of his arm and wrist plus loss of strength at the end of his working day and at home. He performs filing, mousing and computer keyboarding and general clerical duties plus he is required to lift merchandise up to 5 kgs in and out of bins at waist height and above 20 – 30 times per day. He is also required to drive a truck and do deliveries from time to time. He has been diagnosed with an over use injury and has been resting and taking anti-inflammatory drugs for two weeks and is now ready to get back to work. He has to be tested and prepared for work by a Kinesiologist.

Scan Start with a general posture scan with patient standing in functional position. Patient has a poked head Kyphosis Increased Cervicle Lordosis Check for discolouration of limbs, lesions, bruises, capillary refill

Functional Ability Tests 1. Lifting boxes to waist height increasing weight and noting any weakness or pain. 2. Flexion/Extension at wrist and fingers to test for weaknesses or pain in problem area which is the posterior aspect of forearm. Begin without resistance and then slowly increase resistance.

Muscles Muscles for Supination of Forearm Supinator Muscles for Forearm Pronation -Pronator Teres -Pronator Quadratus

Muscles Involved in Movement Extensors of Wrist & Fingers: Extensor Carpi Radialis, Brevis, and Longus Extensor Carpi Ulnaris Extensor Digitorum Communis Extensor Digiti Minimi Lumbricals

Muscles Involved In Movement Flexors of the wrist and fingers: Flexor Carpi Radialis Palmaris Longus Flexor carpi ulnaris Flexor digitorum superficialis Flexor digitorum profundus Lumbericales Flexor digiti minimi

Muscles for Movement Radial Deviation Ulnar Deviation Flexor Carpi Radialis Ulnar Deviation Flexor Carpi Ulnaris Extensor Carpi Radialis Longus/Brevis Extensor Carpi Ulnaris

Joint Limitations - Supination Joint is Humeroradial, superior radioulnar, and inferior radioulnar LIMIT: Tension in pronator muscles, quadrate ligament, palmar radioulnar ligament, oblique cord, and interosseous membrane

Joint Limitations - Pronation Contact of Radius on the Ulna Tension in quadrate ligament, dorsal radioulnar ligament of inferior radioulnar joint, interosseous membrane, supinator, and biceps brachii

Joint Limitations – Flexion of the Wrist Midcarpal and Radiocarpal Joints Tension in the Posterior radiocarpul ligament and posterior joint capsule

Joint Limitations – Extension of Wrist Occurs at Midcarpal and Radiocarpal Joints Limitations: tension in the anterior radiocarpal ligament & anterior joint capsule, contact between radius & the carpal bones

Joint Limitations – Radial & Ulnar Deviation Radial Deviation: Occurs at Midcarpal and Radiocarpal joints Limitations: Tension in Ulnar collateral ligament, ulnocarpal ligament & Ulnar portion of joint capsule, contact between radial styloid process & the scaphoid bone Ulnar Deviation: Occurs at Radiocarpal (Predominantly) & Midcarpal joints Limitations: Tension in the radial collateral ligament & radial position of joint capsule

Joint Limitations - Finger Flexion Joints involved: metacarpophalangeal, proximal interphalangeal, distal interphalangeal MCP: Tension in posterior joint capsule, collateral ligaments; contact between the proximal phalanx and metacarpals PIP: Contact between the middle and proximal phalanx; soft tissue opposition of the middle and proximal phalanges; tension in the posterior joint capsule and collateral ligament DIP: Tension in the posterior joint capsule, collateral ligaments, and oblique retinacular ligament

Joint Limitations - Finger Extension MCP, PIP, DIP MCP: tension in the anterior joint capsule, palmar fibrocartilagenous( palmar ligament) PIP: tension in the anterior joint capsule, palmar ligament DIP: tension in anterior joint capsule, palmar ligament

Range of Motion Two types we deal with: PROM  Passive Range of Motion The range of motion that is achieved when an outside force causes movement around a joint AROM  Active Range of Motion - The range of motion that can be achieved through the action of the agonist muscles for a specific joint movement “Home on the Range: Range of Motion, Know Your Limits” www. everybodyfitness.com”

Active Range of Motion Supination/Pronation of Elbow Substitution/Trick Movement – Supination – Adduction and external rotation of the shoulder, and ipsilateral trunk side flexion. Pronation – Abduction and internal rotation of the shoulder, and contralateral trunk side flexion

Passive Range of Motion Supination/pronation of Elbow Start: Patient Sitting Arm at side Elbow flexed at 90 degrees Forearm in mid position

Goniometer – Pronation/Supination Start: The arm is at the side, and the elbow is flexed to 90 degrees with the forearm in midposition. The wrist is neutral, and the fingers are extended Therapist: The patient stabilizes the humerus using the nontest hand Goniometer Axis: The axis is placed at the tip of the middle digit Stationary Arm: Perpendicular to the Floor Movable Arm: Parallel to the tips of the four extended fingers

Passive Range of Motion Therapist: Stabilizes the humerus with one hand Grasps distal radius and ulna with other hand END FEELS -Forearm is rotated externally for supination -End Feel Firm Forearm is rotated internally for pronation End Feel hard/firm

Active Range of Motion Assesment- Wrist Flexion/Extension Substitution/Trick Movement Wrist ulnar or radial deviation

Passive Range of Motion Assessment WRIST Start: Patient sitting, forearm is resting on the table in pronation, wrist in neutral position, fingers relaxed

Stabilize the Forearm Grasp metacarpals, thumb placed horizontally in palm of hand Apply slight traction to and move hand anteriorly to assess wrist flexion; apply slight traction & move hand posteriorly to assess wrist extension

End Feel Wrist Flexion – Firm Wrist Extension – Firm on Hand Average 120 m Flexion 0-80 degrees Extension 0 – 70 degrees

Goniometer axis – level of ulnar styloid process Stationary Arm – Parallel to longitudinal axis of ulna Movable Arm – Parallel to longitudinal axis of 5th metacarpal Stablize 4th and 5th metacarpal to keep from any deviation

Active Range of Motion – Ulnar and Radial Deviation Substitution/Trick Movement Ulnar or Radial deviation of the fingers, wrist flexion, and wrist extension

Passive Wrist Ulnar and Radial Deviation Start – Sitting Forearm resting on table in pronation Neutral Wrist Hand Hangs over end of table Therapist -Metacarpals from radial aspect (Ulnar deviation) -Grasp metacarpals from ulnar aspect to assess radial deviation End Feel – Ulnar Deviation  Firm -Radial Deviation  Firm/Hard

Goniometer Stabilize forearm Axis--dorsal aspect of wrist over capitate Stationary arm-> midline of forearm Moveable armparallel to longitudinal axis of third metacarpal

Average Range Of Motion Ulnar deviation Thirty degrees Radial deviation Twenty degrees

Metacarpophalangeal Flexion/Extension Start--> Patient sitting Forearm resting on table Wrist in neutral position Fingers relaxed

Therapist Stabilize proximal phalaynx for assessment of PIP and DIP Grasp middle phalaynx to assess PIP or distal phalaynx to assess DIP joint END FEELS PIP flexion-hard/soft/firm DIP flexion- firm PIP extension- firm DIP extension- firm

Goniometer Axis for dorsal surface of PIP or DIP (flexion) Extension palmar surface of PIP or DIP Stationary arm PIP parallel to longitudinal axis of proximal phalanx DIP parallel to longitudinal axis of middle phalanx Movable Arm PIP  Parallel to longitudinal axis of middle phalanx